In 1983 and 1984, six rubella outbreaks in universities and
colleges in four states were reported to CDC's Division of
Immunization, Center for Prevention Services (Table 2). A total of
125 rubella cases were reported, 124 among students and one in a
faculty member. Attack rates varied from 0.2 per 1,000 to
5.4/1,000
among students. Ninety-three (74.4%) of those persons had
inadequate
evidence of immunity (1).* No pregnant students or other pregnant
contacts were identified. No uniform case definition was used to
identify suspected cases in any of these outbreaks. However, most
illnesses were characterized by one or more of the following:
maculopapular rash, lymphadenopathy (cervical, postauricular, or
occipital), low-grade fever, coryza, conjunctivitis, sore throat,
and/or arthralgia. Fifty-two (41.6%) cases were serologically
confirmed as rubella by a positive rubella-specific IgM titer or a
fourfold or greater rise in hemagglutination-inhibition (HI)
antibody
titer. Although three of the colleges had rubella immunization
requirements for school entry, there was little or no enforcement
of
these requirements (Table 2).

In one college, the index patient was a student from South
America
who was incubating disease on arrival to this country. Since all
foreign students attended special English language courses,
subsequent
cases were clustered among other international students. Cases in
the
other colleges clustered among particular dormitories,
fraternities,
and sororities where frequent contact occurred.

As part of outbreak control measures, all the colleges issued
notifications to students, faculty, and other employees urging that
they provide proof of rubella immunity or be vaccinated with a
rubella-containing vaccine. In some schools, outbreak-control
measures also included: (1) reviewing student health records for
immunization status; (2) providing free rubella vaccine at student
health or special vaccination centers for susceptible persons and
persons of unknown immune status; and (3) requesting pregnant women
of
susceptible or unknown immune status to avoid the campus and to
contact a physician in the event of rash illness or exposure.
Mandatory immunization programs or exclusion from the campus of
susceptible or infected persons were not attempted in any of these
outbreaks. Free vaccine, either measles-mumps-rubella (MMR) or
measles-rubella (MR) vaccine, was provided by student health and
local
health department personnel at the student health service clinics
in
five schools. Acceptance of vaccination was poor, ranging from
less
than 50 students in one school (enrollment 37,000) to 1,100
students
in another (enrollment 17,020) (Table 2). Overall, the 1,922
students
vaccinated represented 2.5% of the total enrollment. If it were
assumed that 7,546 (10.0%) of the 75,468 enrolled at these schools
were susceptible (2-4) and that all 1,922 persons receiving
vaccination were actually susceptible (Table 2), then the campus
vaccination control programs would have reached 1,922 (25.5%) of
7,546
of those considered to be at risk for acquiring rubella. In most
instances, the true number of students with records of either
rubella
immunization or serologic evidence of rubella immunity was unknown.

In two colleges--both of which had rubella immunity
requirements--selective reviews of student health records were
undertaken in an effort to estimate the number of potentially
susceptible students. In one, 719 (71.3%) of 1,008 "day" students
lacked acceptable evidence of immunity; in the other, 400 (15.1%)
of
2,648 students lacked acceptable evidence of immunity. Of the
1,119
students considered susceptible in the two schools, 372 (33.2%)
received MR or MMR vaccine as part of control efforts. The
remainder
were notified that they would not be registered in the next
semester
unless they produced records proving rubella immunity. Officials
in
the other schools had to base control measures on students' and
parents' recollections of vaccine status.
Reported by A Ley, MD, Student Health Svcs, Student Health Svcs
staff,
Cornell University, Ithaca, WC Schmidt, MD, Tompkins County Dept of
Health, M Miller, MD, Student Health Svcs, Colgate University,
Hamilton, K Cardina, Regional Immunization Program, J Grabau, PhD,
Bureau of Communicable Disease Control, New York State Dept of
Health;
RR Albanese, J Bicknell, NJ Fiumara, MD, State Epidemiologist,
Massachusetts Dept of Public Health; C Butler, R Gens, State
Epidemiologist, Pennsylvania State Dept of Health; J Chin, MD,
State
Epidemiologist, California Dept of Health Svcs; Div of
Immunization,
Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The 1984 provisional total of 746 reported rubella
cases in the United States is a new record low for rubella and
represents a 23.1% decline from the 1983 total of 970 cases. In
addition, based on the National Congenital Rubella Syndrome
Register
(NCRSR), only two infants with confirmed and compatible cases of
congenital rubella syndrome (CRS) were reported to have been born
in
1984, compared with six in 1983. Although these CRS statistics are
provisional, they reflect the expected continuous decline in
reported
rubella and CRS cases that has occurred as the result of rubella
vaccination. Although both rubella and CRS cases are
underreported,
these observed declines probably represent accurate trends in
disease
incidence, since the degree of underreporting is not expected to
have
changed appreciably over time.

Rubella outbreaks in the university setting illustrate the
potential for outbreaks wherever large numbers of young adults
congregate, since 5%-20% of adolescents and young adults remain
susceptible to rubella and/or measles (2-5). Colleges and
universities have become a primary focus for rubella and measles
activity (6-9), with disease being introduced both from domestic
sources and by foreign importation (7,8). For example, in 1983,
38.1%
of all reported measles cases were college-associated; 19.8%
occurred
on college campuses. No comparable statistics for rubella in
colleges
are available. Undoubtedly, many college outbreaks went
unrecognized
and unreported because many cases of rubella are mild or
subclinical.
For the same reason, the number of rubella cases in the six
reported
outbreaks was also probably underestimated. Unless there is a
sustained awareness among college health personnel that
college-aged
populations represent a significant pool of susceptibles to both
rubella and measles, early recognition and rapid investigation of
reported suspected cases may be seriously delayed. Most schools
lack
the immunization records to accurately identify susceptibles if an
outbreak were to occur. Furthermore, reviewing records and
implementing control programs during an outbreak are costly,
disruptive, and not often effective. Voluntary programs, like
those
used in these outbreaks, have generally resulted in poor
participation
rates and vaccination of many individuals probably already immune.
Mandatory control programs will increase compliance but have been
rarely instituted to date.

Besides being costly and disruptive to campus life, outbreaks
of
rubella and measles pose special health risks to this
childbearing-aged population, which would likely have higher
morbidity
rates from these diseases than children (1,8). No infected
pregnant
women were identified in these outbreaks. Pregnant women were
involved in rubella outbreaks on university campuses in Washington
and
California in 1981; some of these women elected to terminate their
pregnancies (9). The anxiety and disruption of classes associated
with the warnings to and exclusion of pregnant women would have
been
unnecessary if these women had previously had adequate
documentation
of immunity with rubella vaccine. In spite of this recognized
threat,
most colleges lack immunization requirements. A 1984 survey
assessed
measles and rubella requirements among institutions of higher
education in the United States. Preliminary findings suggested
that
as few as 16% of an estimated 1,861 colleges assessed have
requirements for measles and/or rubella immunity as a condition of
attendance. No information on actual enforcement of these
requirements was obtained.

While many serious health issues--ranging from alcohol and drug
abuse to sexually transmitted venereal diseases and suicide--face
college health officials, outbreaks of rubella and measles are
problems with an available solution. The only way to prevent
introduction of rubella on the campus is to have immune students,
faculty, and employees. To support this goal, the American College
Health Association and the Immunization Practices Advisory
Committee
strongly urge educational institutions to consider requiring proof
of
immunity against these diseases as a condition of registration or
employment (1). Both male and female students and staff should be
included in any such requirement. Such a requirement minimizes the
likelihood of rubella or measles being introduced onto the campus
and
places the principal responsibility for assuring adequate
vaccination
status on the student.

Rhode Island and the District of Columbia have had longstanding
college entrance requirements. Rhode Island has required rubella
immunization for college women since 1980 and measles and rubella

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